Who should have priority, the Olympic-sports athlete who came into the athletic training room first, or the starting quarterback who’s needed for Saturday’s sold-out football game? First-come, first-served, right? What if the field hockey player showed up, unannounced, a minute before the football player’s scheduled appointment? What if she’s hurt after working out in direct contradiction to rehab instructions, while the quarterback has followed every order to the letter?

Here’s another scenario: Your new team physician gives a piece of questionable advice. It’s not necessarily harmful, but based on your years of experience, you believe it’s not the best recommendation. Do you speak up and risk poisoning relations between you and the doctor, or do you let it pass and keep a closer eye on things in the unlikely event something goes wrong?

Let’s say you learn that a colleague with a stellar reputation has let her certification lapse. Do you report her? Rules are rules, yet you know she is conscientious, puts athletes’ interests first, and could have her career ruined if this gets out. What do you do?

The thing about ethical dilemmas is that all the easy ones have already been settled. If the right choice were clear, it wouldn’t be a dilemma.

As allied healthcare professionals, athletic trainers are expected to put the well-being of their athletes first. Yet you are also part of a team and a culture that prioritizes winning. This alone can create conflicts that are different from those faced by any other profession. But this position also gives athletic trainers a valuable platform from which to influence others. As healthcare professionals with a responsibility to advocate for their patients, it may be easier to speak up for the right but unpopular thing to do.

“Nearly every decision an athletic trainer makes has an ethical component to it,” says Shane Caswell, PhD, ATC, Assistant Professor of Athletic Training at George Mason University. “It may be subtle. But if your work involves caring for someone, then it has an ethical component to it. And nearly every decision that an athletic trainer makes has something to do with the care of people whom they’re responsible for.”

PROFESSIONAL ETHICSThe National Athletic Trainers’ Association has established a Code of Ethics that sets some general standards for behavior. The code deals with matters such as avoiding conflicts of interest, not using information gained from practicing as an athletic trainer to influence a contest or to gamble, and making only necessary referrals. It also focuses on providing sound care and specifies that members must comply with state laws, remain current in the field, respect confidentiality, not exploit patients in any way, and never place financial gain ahead of the patient’s welfare.

Bill Prentice, PhD, ATC, PT, Coordinator of the Sports Medicine Program at the University of North Carolina, says he approaches ethical problems by remembering that his primary allegiance is to the athlete. “The decisions that we make regarding appropriate healthcare should be based almost entirely on what is best for the athlete without regard to pressures that may come from coaches or administrators, or in some cases alumni,” he says.

Tim Laurent, EdD, ATC, Athletic Training Program Coordinator at Lynchburg College, starts his decision-making the same way. He keeps in mind that he works for the athlete, his patient. Then he takes it a step further, looking at the athlete’s best long-term interests. “For example, we just talked in class about an athlete who injured his ACL and discussed whether he should play,” Laurent says. “I said the way to look at it is not whether he can play now, but how is he going to feel five or 10 years down the road? No matter what the injury is, that’s how I look at it.”

What if a physician gave advice that is less than ideal, though not blatantly wrong or dangerous? Laurent says he’d ask the physician to reconsider. “I have a higher obligation to the athlete than I do to the physician,” he says. “Of course, I need to approach that conversation in a professional way, but I would put protecting the patient’s health above not bruising the physician’s ego.”

Gretchen Schlabach, PhD, ATC, Athletic Training Program Director at Northern Illinois University, is researching a book on professional ethics. She believes the setting of competitive athletics should not dictate athletic training’s ethics at all. “An athletic trainer in the intercollegiate setting should have the same standards as an athletic trainer working in a hospital setting,” Schlabach says. “We expect nurses to behave the same in an intercollegiate setting as they do in a hospital setting. Why should athletic trainers be different?”

PRIORITIZING VALUESBut sometimes, the ethical questions can be a lot more complicated. Jeff Konin, PhD, ATC, PT, Assistant Athletic Director for Sports Medicine and Associate Professor of Health Sciences at James Madison University, faced a difficult situation a couple years ago when a male archery student-athlete began having seizures. He was diagnosed with a rapidly progressing brain tumor, leaving him with only weeks to live. One of his greatest pleasures in life was archery, and he begged to be allowed to continue. Konin and others in the athletic department were torn. They wanted to allow the young man the pleasure of his sport in his last few weeks, but they also had to consider the safety of others should he have a seizure on the range.

Ultimately, it came down to analyzing the risks and benefits to the athlete and others. Administrators decided that the archer’s presence would be an unusual circumstance posing risks beyond those anyone would normally be willing to take by entering the range. That, coupled with the potential severity of injuries caused by an errant arrow, convinced them the best decision was to not let the athlete take part. “We couldn’t risk that he might have a seizure out there while holding a bow and arrow in his hand,” Konin says.

When it comes to making these bigger decisions, Caswell says it’s often necessary to take a step back and follow a plan. He explains that many ethicists see four components in moral decision-making: First, a person must recognize that there is a moral dilemma. Second, he or she must make a moral judgment. Third, a person has to be able to prioritize what they value. And fourth is the persistence and courage to implement a moral choice.

The third component on that list—being able to prioritize what you value—is the area of ethics that can be trickiest. Most of us have a values system, but it takes some thought to know how your individual values relate to decision-making within your profession.

“When I was a graduate student I had an ethical dilemma that I took to one of my mentors,” Caswell says. “This individual said to me, ‘Shane, decisions are easy when your values are clear.’” That wasn’t a way of saying that things should be made black and white, but simply that decisions are easier when a person has sorted out and prioritized what’s important. Caswell then had to step back and prioritize those values in play.

Schlabach suggests that among athletic trainers, values might include caring, honesty, accountability, promise keeping, excellence, loyalty, fairness, integrity, respect, and responsible citizenship. She suggests that athletic trainers think about how their values relate to their work and how one might trump another in a specific situation.

“We’ve been teaching our kids right from wrong since day one. When you get into ethics, it’s a gray area,” Schlabach says. “You might honor loyalty in one circumstance, but then honor honesty in the next circumstance and give loyalty a back seat.”

BRINGING IN OTHERSAnother critical aspect of making ethical decisions is to include others in the process. To start, make sure you understand where your coaches are coming from. And don’t assume your standards are more important than theirs.

“Coaches have a mission to perform well athletically, and they should be allowed to have that,” Laurent says. “Athletic trainers have a mission to make sure that the athletes are safe. When you talk to coaches at a time they can be reasonable, they will say, ‘I need you to tell me what I need to do regarding injured players because that is not my area of expertise. You need to keep me straight during a game because I won’t do it by myself.’ That doesn’t mean they’re unethical. It’s only saying their focus is on athletic success.”

Joe Gieck, EdD, ATC, PT, retired Head Athletic Trainer and Professor Emeritus in Sports Medicine at the University of Virginia, agrees. “Coaches will push—and they should—and you should really try to see their side,” he says. “We should remember that our job as athletic trainers is to get athletes ready as quickly and safely as possible. Don’t make it a power thing by saying, ‘He can’t play because I said so.’”

Of course, the injured athlete must also be included in the discussion. For example, if there is a once-in-a-lifetime opportunity to play for a championship, couldn’t the athlete choose to risk acceptable long-term harm for a chance to take part? Is it really the athletic trainer’s place to make that decision alone?

“I think that adults should be able to make some decisions for and about themselves,” says Laurent. “So with college athletes, if the situation allows it, I will explain things to them so that they can make an informed decision. If I am working with high school athletes, who typically are minors, I give them less say about the process, but if time allows it, their parents are involved before a decision is made.”

It can also help immensely to talk to a peer who has no connection to the situation. “Probably one of the best things about working as an athletic trainer is that everybody has a mentor at some phase in his or her professional development,” Prentice says. “Part of mentoring means being able to go to that person and seek their advice. It doesn’t necessarily mean you’ll take their advice, but it always helps to bounce ideas off other individuals.”

MAKING IT CLEARBeing ethical also means setting up policies and procedures that let everyone know what your values are. This will make it easier to talk with others about decisions that need to be made, and it will relieve you from having to make tough decisions every day.

One of the clearest examples involves which athletes get treated first. Laurent says he follows a rule that gives priority to in-season athletes, then it’s first-come, first-served. The idea is to let everybody know how you prioritize and what you deem fair. This is particularly important for athletic trainers with multiple teams and many athletes to take care of.

“Things are always going to happen,” Laurent says. “But if you’ve remained consistent with what you’ve said you would do, although people might not like it, at least they’ve heard it ahead of time.”

Prentice tries to be flexible when unusual circumstances arise, but by clearly publicizing his rules, it is very clear which things are not up for discussion. “I don’t make an issue of it,” Prentice says. “But you have to send out a message that says, ‘This is the way it is. If you don’t like it, you’d better find somebody else.’”

Gieck suggests posting a simple statement or set of goals that touches on ethics as a way of projecting what is important to you. “It might say, ‘Our aim is to provide the best care for athletes without discrimination,’” he says. That lays the groundwork for equal treatment of athletes from both high-profile revenue teams and low-profile Olympic sports.

Speaking up when something unethical is going on will also let others know your stance. Gieck says it’s especially important to act immediately in circumstances of hazing, sexual abuse, and substance abuse. In situations of lesser urgency, Gieck recommends non-confrontational, tactful questioning to make sure others are considering the ethics of a decision, while making it clear you want no part of condoning questionable behavior.

“Ask them to think about whether what they’re doing is right,” Gieck says. “If you stand up and say you won’t be compromised on these issues, when something comes up, you can say it’s something you won’t involve yourself in.”

Ultimately, being ethical may come down to sheer will. The ethical choice may be the hard choice, and the right stance the unpopular stance. In those cases, think about the effect on the profession and the athlete. With so much at stake, the choice may not be so hard after all.

SidebarDeep ThoughtsAthletic trainers in academia are beginning to study how practitioners confront and resolve ethical problems and what the field’s collective core values are. Their discussions may seem far removed from people in the workday trenches, but their approach can help athletic trainers think through their ethical standards and behaviors to better represent the profession.

There are two main theories or moral philosophies that scholars have identified to help examine ethics, says Shane Caswell, PhD, ATC, Assistant Professor of Athletic Training at George Mason University, who has researched how athletic training students make ethical decisions. In one, the objective is to pick the option that will do the greatest good—or avoid the most harm—for the greatest number of people. It’s an ends-justify-the-means approach. In an athletic training example, it could mean that while letting the quarterback return to play might expose him to pain in middle age, it might also mean the team will win, creating happiness for all 100 members.

The other approach is a justice-based theory. A person judges an act on what duties one has in society. Questions come down to what’s right, not the outcome.

When it comes to deciding what’s right, many ethicists say there are several levels of sophistication among individuals. The first is based only on punishment and obedience, such as what young children learn: A particular act is wrong because a parent or teacher says so, and you’ll be punished if you get caught. Then there’s ethics based on the desire to be perceived as good and meeting societal norms. Finally, the most advanced ethical thinkers use certain moral principles, such as human rights or social justice, and even universal ethical principles, says Caswell.

Gretchen Schlabach, PhD, ATC, Athletic Training Program Director at Northern Illinois University, is researching what athletic trainers believe are the profession’s core values—those virtues that, when taken together, make the essence of a universal athletic training ethic. “Everything else is wrapped around those professional values, and that core is our professional ethics,” she says. “Some are easy, such as confidentiality and excellence in providing the best care. But other values might be more implicit, like honesty.”

Articulating core professional values, as some other allied healthcare professions have done, could be another step in deepening athletic training’s professionalization, Schlabach says. She is concerned that the profession sometimes lets outsiders dictate athletic training ethics at its practitioners’ expense. “If we’re going to be strong and have some sense of our professional identity and distinctness, we can’t allow the setting to dictate who and what we are,” she says.

SidebarLegislating MoralsA professional organization that asks its members to work ethically can’t assume everyone involved agrees on what that means, especially when definitions of “ethical” shift over time. This was the thinking of the Ohio Athletic Trainers’ Association (OATA) when it began requiring members to complete an hour of ethics training every two years for relicensing.

The main reason for the mandate, OATA President Bill Kulju, MS, LAT, ATC, says, was that many new members of the growing association were not familiar with the OATA constitution, bylaws, and code of ethics they’re obligated to follow. The move was also seen as a way to reduce the number of ethics-related complaints filed against athletic trainers. But the leadership also recognized that not everyone agrees on what is and isn’t ethical.

“Our society has changed so much,” says Kulju. “What an older generation perceives as unethical may be considered ethical to a younger generation. We have to discuss what’s ethical and what’s unethical on a regular basis, and make sure we’re all on the same page.”

The hour of ethics training can take many forms, such as a session pertaining to ethics at OATA, NATA, or Great Lakes Athletic Trainers’ Association symposiums. A session, for example, might cover how to handle parents’ requests to not disclose anything about their son’s or daughter’s injury when other people in the school should have the facts, and the ethics of telling a coach the results of an in-game evaluation within earshot of other people.

“In the broadest sense, we’re trying to get our members to understand what is and is not ethical behavior based on a wide range of examples, whether it’s interaction with athletes, coaches, parents or the media,” Kulju says. “It’s important to our members to be sure that we are promoting the profession in a positive light.”